Ann Thorac Surg 2008;85:1466-1467. doi:10.1016/j.athoracsur.2007.10.010
© 2008 The Society of Thoracic Surgeons
How To Do It
Technique for Insertion of the Inflow Cannula of the INCOR Left Ventricular Assist Device
Takeshi Komoda, MD, PhD*,
Yuguo Weng, MD, PhD,
Roland Hetzer, MD, PhD
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
Accepted for publication October 2, 2007.
* Address correspondence to Dr Komoda, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, Berlin, 13353, Germany (Email: komoda{at}dhzb.de).
| Drs Weng and Hetzer disclose that they have a financial relationship with Berlin Heart AG.
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Abstract
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Our insertion technique for the inflow cannula of the INCOR left ventricular assist device (Berlin Heart AG, Berlin, Germany) is as follows. The apex ring is secured to the left ventricular apex using eight horizontal mattress sutures with full-thickness bites of myocardium. Another eight horizontal mattress sutures are then placed first through the Dacron felt pledgets (DuPont, Wilmington, DE) of the previously placed mattress sutures and then through the myocardium, the apex ring, and the suture collar of the inflow cannula. A double purse-string 3-0 polypropylene suture is placed on the Dacron pledgets around the apical hole and tightly tied.
The INCOR left ventricular assist device (LVAD; Berlin Heart AG, Berlin, Germany) was first implanted in June 2002, and as of July 31, 2007, the device had been implanted in 364 patients in 16 countries, including 140 patients at our center. After our introduction of an implantation technique for the device [1], a modified technique was reported from another hospital [2]. One of us (Yuguo Weng) uses another technique, which has been applied in 58 patients. Because this technique is effective for hemostasis at the site of insertion of the inflow cannula into the left ventricle (LV), we describe it in detail to facilitate further clinical use of the INCOR (Berlin Heart AG) system worldwide.
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Technique
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After institution of cardiopulmonary bypass, the LV apex is elevated out of the pericardial sac, the heart is electrically fibrillated, and the LV apex is cored with a scalpel. Eight mattress sutures of 3-0 monofilament polypropylene pledgeted with Dacron felt (DuPont, Wilmington, DE) are placed circumferentially around the apical hole. The needle for the mattress suture is exited from the apical hole taking full-thickness bites of myocardium. These sutures are then passed through the apex ring. The apex ring is placed on the LV apex and the sutures are tied (Fig 1). The inflow cannula is inserted into the LV through the apical ring. A suction tube is connected to the inflow cannula and the LV is vented. An additional eight mattress sutures pledgeted with Dacron felt (DuPont) are placed to secure the inflow cannula to the apex ring, passing through the Dacron felt pledgets of the previously placed mattress sutures, then through the myocardium, the apex ring, and the suture collar of the inflow cannula (Fig 2). A double purse-string suture of 3-0 polypropylene is placed on the Dacron pledgets around the apical hole (Fig 3) and tightly tied.
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Fig 1. The apex ring is sutured to the left ventricular apex with eight mattress sutures placed circumferentially around the apical hole with full-thickness bites of myocardium.
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Fig 2. The eight overlapping mattress sutures are placed, which are first passed through the Dacron felt pledgets (DuPont, Wilmington, DE) of the previously placed mattress sutures and then through the myocardium, the apex ring, and the suture collar of the inflow cannula.
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Fig 3. A double purse-string suture of 3-0 polypropylene is placed on the Dacron felt pledgets (DuPont, Wilmington, DE) around the apical hole and tied tightly.
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Comment
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In the INCOR clinical manual, the manufacturer recommends that the suture collar of the inflow cannula be fixed to the apex ring using a running suture. Our original introduction of an implantation technique for the device [1] describes sewing of the inflow cannula to the apex ring in this manner, and a modified technique from another hospital [2] describes improvement in suture fixation of the inflow cannula to the apex ring using fewer sutures, to shorten the operation time. With our technique, the suture collar of the inflow cannula is not fixed directly to the apex ring, but eight interrupted horizontal mattress sutures are used to combine the suture collar of the inflow cannula, the apex ring, myocardium and Dacron felt pledgets which were previously placed around the apical hole.
Our insertion technique for the inflow cannula consists of three steps: (1) securing the apex ring to the LV apex using eight mattress sutures with full-thickness bites of myocardium, (2) securing the inflow cannula to the LV apex using eight overlapping mattress sutures that are anchored to the Dacron felt plegets of the previously placed mattress sutures, and (3) placing a double purse-string suture of 3-0 polypropylene on the Dacron pledgets around the apical hole.
Prevention of postoperative bleeding from the LV apex is crucial for LV apical cannulation with any LVAD. Because the myocardium of the LV apex is thin and fragile, the second step is important to avert cutting the myocardium with the sutures. To prevent bleeding from the apical hole, the third step is effective. Of 58 patients who underwent implantation of the INCOR LVAD using this technique, none required reoperation because of bleeding from the LV apex after device implantation.
For the mattress sutures fixing the inflow cannula to the LV apex, full-thickness bites of myocardium have been recommended [3-5]; however, it is necessary to avert traction of the sewing ring into the LV when the needle for the mattress suture is exited from the apical hole [3]. Our steps 1 and 2 meet these requirements.
Our technique for LV apex cannulation was used for implantation of the Novacor left ventricular assist system (LVAS; WorldHeart Inc, Oakland, CA) until 2001, and since 2002 it has been used for implantation of the INCOR LVAD. The technique is effective in averting bleeding at the LV apex, and we believe that, with appropriate modifications, it can be applied to other types of LVADs [6].
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Acknowledgments
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We thank Anne M. Gale, Editor in the Life Sciences, Deutsches Herzzentrum Berlin, for editorial assistance.
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References
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- Hetzer R, Weng Y, Potapov EV, et al. First experiences with a novel magnetically suspended axial flow left ventricular assist device Eur J Cardiothorac Surg 2004;25:964-970.[Abstract/Free Full Text]
- Tschirkov A, Nikolov D, Papantchev V. New technique for implantation of the inflow canula of Berlin Heart INCOR system Eur J Cardiothorac Surg 2006;30:678-679.[Abstract/Free Full Text]
- Slater JP, Williams M, Oz MC. Implantation techniques for the TCI HeartMate ventricular assist systems Operative Techniques Thorac Cardiovasc Surg 1999;4:330-344.
- Westaby S, Frazier OH, Pigott DW, Saito S, Jarvik RK. Implant technique for the Jarvik 2000 heart Ann Thorac Surg 2002;73:1337-1340.[Abstract/Free Full Text]
- Kormos RL. Insertion of Thoratec LVAD (BiVAD). The Cardiothoracic Surgery Network (CTSNet) Experts’ Techniques: Adult Cardiac Surgical Techniques. http://www.ctsnet.org/doc/2384 2002Accessed Aug 21, 2007.
- Komoda T, Weng Y, Nojiri C, Hetzer R. Implantation technique for the DuraHeart left ventricular assist system J Artif Organs 2007;10:124-127.[Medline]
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Abstract
Introduction
